Provider Demographics
NPI:1790213064
Name:PEBBLE CREEK MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:PEBBLE CREEK MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMMAKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-337-6897
Mailing Address - Street 1:18210 N ORGAN PIPE DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-1757
Mailing Address - Country:US
Mailing Address - Phone:602-410-6951
Mailing Address - Fax:480-304-3234
Practice Address - Street 1:700 N ESTRELLA PKWY # 130
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9271
Practice Address - Country:US
Practice Address - Phone:623-322-2144
Practice Address - Fax:623-322-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ281108Medicaid